Wound Healing Trajectories to Determine Pressure Ulcer Treatment Efficacy

Background: Wound healing trajectories (percent healing vs time) provide a dynamic picture of the decrease in wound burden over the entire continuum of the healing process. Trajectories can be robustly compared using survival statistics methodology. Improvement in healing can be determined by shifting the curve from “impaired” healing toward “ideal” healing. Although this concept of shifting the curve “to the left” has been demonstrated in acute incisional healing depicted by the gain in tensile strength, and in other chronic wounds, it has not been utilized for chronic pressure ulcers. Methods: Wound healing trajectories were constructed for 211 patients enrolled in 8 separate randomized clinical trials for grade III and IV pressure ulcers. Trajectories were constructed for patients achieving ≥90% or more healing within 112 days and those who achieved less than <90% wound closure. Kaplan-Meier curves were constructed for all patients receiving an experimental treatment and for those receiving placebo vehicles. Results: Different trajectories were achieved for the faster healing patients. Eighty-one percent of patients reached 90% healing within 112 days; 80% of those in treatment groups and 85% of those in placebo groups. Linear regression suggested that all patients entered into the clinical trials would achieve 90% healing by 18 weeks. Only 17% of the patients achieved total healing (100% wound closure) within the 112-day study period. Linear regression suggested that it would take 110 weeks to achieve total healing in all patients. Conclusion: Wound healing trajectories provide a more complete description of treatment efficacy than do fixed endpoints, such as the number of patients achieving 100% closure at one defined time point. Since more successful healers have different trajectories than less successful healers, shifting the trajectory to the left from “impaired” toward “ideal” healing may provide a better endpoint to determine treatment efficacy.